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Metaphor is a central tool of the therapist of many therapeutic modalities, and they are a particular feature of CBT. Metaphors can be essential tools in the therapeutic process; providing the therapist with a means of communicating potentially complex psychological concepts and theory to clients, and also being part of the process of change. This paper presents a series of metaphors that some of the most experienced and innovative practitioners in the world of CBT have found to be helpful. Each practitioner describes how to utilize the metaphor skilfully and effectively: providing some tips for facilitating both the presentation of metaphors to, and eliciting of metaphors from the client; and demonstrating how the use of metaphor can facilitate therapeutic change. Overall, the small selection of metaphors presented here demonstrate the great versatility of metaphor to address all kinds of issues in therapy, with a range of client groups and presenting difficulties; and how the shared exploration and collaboration of both client- and therapist-generated metaphors can be an important addition to the therapist's toolbox.

Returning to the scene of the trauma is often recommended as part of trauma-focused cognitive-behavioural therapies for post-traumatic stress disorder (PTSD). Many clinicians avoid site visits due to lack of confidence or practical constraints; however, recent research suggests this is a valuable part of treatment. This article summarizes a rationale for including the site visit as part of cognitive therapy for PTSD, as well as the main considerations about when to carry it out in treatment. A practical framework for planning and implementing site visits is described.

Conversations around improving access to psychological therapies for BAME (Black, Asian and minority ethnic) service users have been ongoing for many years without any conclusion or resolution. BAME service users are often under-represented in primary care mental health services, and often have worse outcomes, leading to them being portrayed as ‘hard to reach’, and to deterioration in their mental health. They are over-represented in secondary care mental health services. The authors of this article argue that more resources are required in order to understand the barriers to accessing mental health services, and improve both access and recovery for BAME service users. This paper examines concepts such as race, ethnicity and culture. It aims to support service managers and therapists to develop their confidence to address these issues in order to deliver culturally competent psychological therapies to service users from BAME communities, with a focus on primary care. It is based on our experiences of working with BAME communities and the feedback from our training events on developing cultural competence for CBT therapists. The paper also discusses the current political climate and the impact it may have on service users and the need for therapists to take the wider political context into consideration when working with BAME service users. Finally, the paper stresses the importance of addressing structural inequalities at a service level, and developing stronger ethical guidelines in the area of working with diversity for CBT therapists in the UK.

Key learning aims

(1)To examine concepts such as race, ethnicity and culture and to provide a shared understanding of these terms for CBT therapists.

(2)To assist CBT therapists and supervisors to develop their confidence in addressing issues of race, ethnicity and culture with BAME service users within the current political climate and to deliver culturally competent therapy.

(3)To assist service managers to promote equality of access and of outcomes for service users from BAME communities.

(4)To understand how unequal expectations of therapists in services impacts on CBT therapists from BAME communities.

(5)To widen understanding of some of the structural inequalities at service level which the CBT community needs to overcome, including recommending stronger ethical guidelines around working with diversity in the UK.

Clinical supervision is regarded as one of the most important components of psychotherapy training. In clinical practice, it has been found that the implementation of clinical supervision varies substantially and often differs from the recommendations made in the literature. The objective of the current study was to investigate the frequency of topics (e.g. ethical issues) and techniques (e.g. role play) in the clinical supervision of psychotherapy trainees in Germany. To this end, we considered supervisions in cognitive behavioural therapy (CBT) and psychodynamic therapy (PT). A total of 791 psychotherapy trainees (533 CBT and 242 PT) were asked via the internet to provide information about their current supervision sessions. We found that clinical supervision in psychotherapy training addressed topics that are central for the effective treatment of supervised patients (i.e. therapeutic interventions, therapeutic alliance, maintaining factors, and therapeutic goals). However, the most frequently used intervention in clinical supervision in psychotherapy training was case discussion. Rarely were techniques used that allowed the supervisor to give the supervisee feedback based on the supervisee's demonstrated competencies. For example, 46% of the supervisors never used audiotapes or videotapes in the supervision. Differences between CBT and PT were rather small. Current practice regarding the techniques used in clinical supervision for psychotherapy trainees contradicts recommendations for active and feedback-oriented clinical supervision. Thus the potential of clinical supervision might not be fully used in clinical practice.

This article describes a clinical protocol for supporting those presenting with post-traumatic stress disorder (PTSD) and dissociative symptoms, particularly dissociative flashbacks, based on a cross-culturally applicable model. The protocol is discussed from the perspective of working with a refugee and asylum seeker population, although many of the principles will be applicable to clients from any background presenting with these dissociative symptoms. The protocol addresses the assessment and formulation of a client’s dissociative symptoms. It includes guidance on sharing psycho-education with clients regarding the evolutionary function of dissociation and developing practical strategies to monitor and manage dissociative symptoms. The strengths and limitations of this protocol are also discussed.

Key learning aims

After reading this article people will:

(1)Be able to understand a cross-culturally applicable model of dissociation and how it applies to clinical practice when working with clients presenting with dissociative symptoms, particularly dissociative flashbacks, in the context of a diagnosis of PTSD.

(2)Be able to assess and formulate dissociative symptoms as part of an overall PTSD formulation.

(3)Be able to develop practical strategies for assisting clients in monitoring and managing their dissociative symptoms.

(4)Be familiar with adaptations for using this approach with refugee and asylum seeker populations.

Research in the field of cognitive behavioural therapy (CBT) has primarily focused on the acquisition and development of skills and competence. Little is known regarding the experience of training from trainees’ perspectives. This systematic review aimed to review and critique the research conducted on the experience of CBT training. Four electronic databases were searched for published studies reporting on the experience of CBT training. Thirteen articles were selected based on pre-determined inclusion and exclusion criteria and were assessed for quality using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD; Sirriyeh et al., 2012). Due to the lack of consistency in the study designs and outcome measures used, a narrative synthesis of the findings was conducted. Findings were categorized within three themes for synthesis: ‘experience of benefit’, ‘internal processes of engagement’ and ‘external influences on engagement’. Overall, this review was able to draw conclusions regarding the experiences of aspects of CBT training from relatively good quality research. However, the review also highlights the lack of studies exploring specific hypotheses regarding the experience of training.

There has been limited application of cognitive behavioural therapy (CBT) to the treatment of distressing visual hallucinations (VH) in people with psychosis. Preliminary research applying interventions to a novel presenting issue are enhanced by utilizing designs that allow strong inferences to be made about the effect of the intervention. Hence, this study aimed to measure change in appraisal, affect, and behaviour as a consequence of CBT VH, to improve understanding of the process of change. A multiple-baseline experimental single-case design methodology was used with five participants who received a CBT VH treatment package. Participants used daily diary measures to record appraisals, affect, and behaviours related to the distressing VH. Standardized measures were completed at each phase change. Four individuals completed therapy. Formal visual analysis of the data supported by statistical analysis indicated significant changes for appraisal and affect, with replication across three participants. Changes in frequency of VH were reported in two cases. Change was not evident on the standardized measures. This study replicates and extends the findings in showing potential value of CBT VH. Further research should consider alternative methods of capturing behavioural change. Attempts should also be made to replicate across therapists and centres.

Psychoeducation courses have gained some empirical support as effective early intervention strategies. Many of these courses reflect traditional cognitive behaviour therapy (CBT) thinking but psychoeducation courses based on other approaches are beginning to emerge. One such course, ‘ACTivate Your Life’, is based on acceptance and commitment therapy (ACT). The aim of this preliminary investigation is to evaluate a four-session (eight-hour) ACT psychoeducation intervention delivered within the Abertawe Bro Morgannwg University (ABMU) Health Board. Participants were invited to complete four outcome measures (assessing depression, anxiety, self-esteem and life satisfaction) and two process measures (assessing mindfulness self-efficacy and psychological flexibility) at pre- and post-intervention. Statistical analysis indicated that participants’ scores across each of the measured domains showed highly significant changes. These results suggest that a brief psychoeducation ACT course may be useful in helping people in need of early psychological intervention, and that further research is now needed to provide a definitive evaluation of its effectiveness.

Within IAPT (Improving Access to Psychological Therapies), cognitive behavioural therapy (CBT) is offered to all clients regardless of gender, religion, culture and language. Hence, the demand for working with interpreters to facilitate communication during therapy in IAPT has increased. This study explored the experience of therapists working with interpreters to facilitate communication in psychological therapies with clients with mild to moderate anxiety and depression including those with co-morbid physical health problems. Thirteen participants, including six CBT therapists and seven Psychological Wellbeing Practitioners (PWPs) working in an NHS IAPT service, were interviewed. A qualitative approach, using semi-structured interviews and thematic analysis (Braun and Clarke, 2006), was implemented. The following four major themes were identified from the participants’ accounts: negotiating a three-way communication, difficulties in expressing empathy, a lack of shared understanding and working creatively with interpreters. During this collaborative working new understandings of engaging emerged leading participants to view this work as possible.

Transdiagnostic cognitive behavioural therapy (T-CBT) provides potential for improving psychotherapy services in countries with limited resources. The primary aim of this study was to assess the feasibility and potential benefits of using T-CBT in Saudi Arabia to treat adult emotional disorders in a naturalistic open trial. A secondary aim was to measure the effect of this approach when delivered by junior psychologists as a low-intensity intervention. The overall sample consisted of 198 patients (160 in the low-intensity group). Only 33 (16.7%) patients had completed the treatment plan, 55 (27.3%) were still active in treatment, and 109 (55%) had disengaged from the treatment. The pre- and post-assessments for the clients who completed the treatment showed a significant decrease in all outcome measures. This result held true for the whole sample and the low-intensity group. This study provides initial evidence that T-CBT is suitable for clients with emotional disorders in Saudi Arabia. The study also provides support for the effect of T-CBT as a low-intensity intervention delivered by junior psychologists. However, one of the study limitations was the sample size for the group who completed the treatment and was properly discharged from service. Implications and recommendations are discussed.

Key learning aims

(1)To examine the feasibility and potential benefits of using T-CBT in Saudi Arabia.

(2)To measure the effect of T-CBT as low-intensity interventions delivered by junior psychologists.